Impact Of Routine Surveillance Duplex Ultrasound And Subsequent Reintervention After Superficial Femoral Artery Stenting On Amputation-free Survival
Michael Shih, MD, Alejandro Pizano, MD. MSBME, Jesus Porras-Colon, MD, Jacqueline Babb, MD, Carlos H. Timaran, MD, Shadman M. Baig, MD, Michael Siah, MD, Gerardo Gonzalez-Guardiola, MD, Melissa L. Kirkwood, MD.
University of Texas Southwestern Medical Center, Dallas, TX, USA.
OBJECTIVES: In-stent restenosis is a major problem following superficial femoral artery (SFA) stenting. Duplex surveillance can identify patients who develop restenosis; however, many patients who are stented may not be followed routinely due to varying practice patterns. The purpose of this study was to evaluate whether surveillance and reintervention improves outcomes in patients with SFA stents.
METHODS: A single-center, retrospective study was performed with patients undergoing SFA stenting between 2005-2020 who had a follow-up (1, 3, 6, 12 months, and annually) with duplex ultrasound. Demographics, clinical characteristics, and imaging results were recorded. Five groups were identified based on the presence of in-stent stenosis (peak systolic velocity ratio >2) on duplex (stenosis [ST] vs. no stenosis [NST]), recurrence of symptoms (symptomatic [SX] vs. asymptomatic [ASX]), and if reintervention was performed (reintervention [R] vs. no reintervention [NR]): 1. ST+SX+R; 2. ST+SX+NR; 3. ST+ASX+R; 4. ST+ASX+NR; 5. NST+NR. Reintervention was performed at the provider's discretion based on symptom status and the risk/benefit of reintervention. The primary endpoint was amputation-free survival, and the secondary endpoint was patency. RESULTS: Two hundred fifty-seven patients were analyzed with a mean age of 64±11 years. 57% were male, 68% had diabetes, and 36% had chronic total occlusion, 72% had chronic limb-threatening ischemia. 161 (63%) patients underwent reintervention. Patient characteristics were well matched between groups. Figure 1 shows the probability of amputation-free survival. Those who were symptomatic and did not undergo reintervention (ST+SX+NR) had the worst outcome, while those who were asymptomatic and did undergo reintervention (ST+ASX+R) had the best outcome. Asymptomatic patients with restenosis did better with reintervention versus those who did not undergo reintervention. Loss of patency was higher in those where stenosis was identified, but no reintervention was performed. Predictors of patency were the absence of diabetes and chronic total occlusion and active follow-up (>3 visits; 0.14 [0.2-0.9], P=.044). CONCLUSIONS: Routine surveillance duplex and subsequent re-intervention on significant in-stent stenosis after SFA stenting is associated with improved patency and amputation-free survival. Active surveillance should be done for all, with reintervention strongly considered for in-stent restenosis for both symptomatic and asymptomatic patients. 
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